SLEEPING WITH THE ENEMY: The Global AIDS Crisis

Thursday, August 26, 2004

The global AIDS pandemic is now in its third decade. Although treatments have improved and infection rates have slowed in the West, AIDS continues to take a staggering toll in Africa. And experts believe that Eurasia, particularly Russia, China, and India, may be next. Is the United States doing enough to combat the global AIDS crisis? Should the United States continue its current policy, which includes an emphasis on getting antiretroviral drugs to millions who can't now afford them? Or does the United States need to focus more on pressuring affected countries to reform their inadequate social and economic institutions? Peter Robinson speaks with Carol Adelman and Greg Behrman.

Recorded on Thursday, August 26, 2004

Peter Robinson: Today on Uncommon Knowledge: is the United States passing the HIV test?

Announcer: Funding for this program is provided by the John M. Olin Foundation.

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Peter Robinson: Welcome to Uncommon Knowledge. I'm Peter Robinson. Our show today: is the United States doing enough to combat AIDS around the world? We are now in the third decade of the global AIDS pandemic. Treatments have improved, and infection rates have fallen here in the United States and in other countries in the West. But in sub-Saharan Africa, AIDS continues to take a staggering toll. Experts believe that Eurasia, and in particular India, China and Russia, will be next. The policy of the Bush administration? To provide anti-retroviral drugs to several million people who can't afford them. But is several million people enough? Indeed is the entire effort misguided? Should we be focusing not on drugs but on strengthening the political and economic institutions of the affected countries?

Joining us today: two guests. Karen Adelman is a fellow at the Hudson Institute. Greg Bearman is the author of The Invisible People: How the United States Has Slept Through the Global AIDS Pandemic, the Greatest Humanitarian Catastrophe of Our Time.

Title: Sleeping With the Enemy

Peter Robinson: Nicholas Eberstadt in Foreign Affairs, quote: "In the decades ahead the center of the global HIV-AIDS pandemic is set to shift from Africa to Eurasia. The death toll in that region's three pivotal countries--Russia, India and China--could be staggering." Close quote. Exaggeration, or a calm statement of the facts? Carol?

Carol Adelman: Calm statement of the facts.

Greg Bearman: Highly possible.

Peter Robinson: All right. Greg, let me begin now by quoting you to yourself. "Throughout the pandemic's 20-year flight, the United States has shrunk from its strategic imperative and its moral obligation, failing at almost every turn to lead a comprehensive global response to the pandemic," close quote. What is it that would make AIDS in Nigeria or Ghana or South Africa the moral obligation of taxpayers in Indiana or Oklahoma or Texas?

Greg Bearman: Well, I think this is the greatest humanitarian catastrophe of our time. I think this is sort of our holocaust. You have over the past 20 years 60 million people around the world have become infected. 20 million have died. In southern Africa every single country is either nearing or has exceeded a 20 percent adult infection rate. This is just decimating societies. It's going to have profound strategic, economic and security implications. I think given the human toll, given our interest, we have a vested interest in doing a lot more. And what I found in the history was that we could have done so much at so many turns, but we failed to.

Peter Robinson: No hold on. You've got two--I want to tease out both of these--you've got two strands of thought here, I think.

Greg Bearman: Right.

Peter Robinson: One is the notion of a moral obligation , and you said this is our Holocaust. Do you really want to say that this is our Holocaust? The Holocaust was what the Nazis did to the Jews, and AIDS is just, there is a fundamental moral distinction, isn't there, that has to be made, in that most people who are infected with AIDS become infected by behavior that they can avoid.

Greg Bearman: In a sense I think you can think of this as a passive genocide. We were sort of letting this happen. I don't want to sort of get bogged into analogizing or--and that sort of debate. I think if you just look at the objective...

Peter Robinson: But you opened the debate. I just want to know how it's a moral obligation of some church-going family in Kansas...

Greg Bearman: Right.

Peter Robinson: --that somebody who is sexually promiscuous, you have to say it, that's one of the ways, primary ways, that the disease is spread, somebody is sexually promiscuous in Ghana, who in some sense ought to or pretty easily could know better, why is that a moral obligation? Karen, what is your feeling about that?

Carol Adelman: I wouldn't completely reject it, because I think Americans have a, we have a strong, generous, philanthropic thrust. Humanitarianism has always had a--our foreign policy has always had a moral dimension to it. And I think that's an important dimension. That distinguishes us from other countries.

Peter Robinson: And then the second strand is that you mentioned that it's in our vested interest. What, why is it in our interest to address AIDS elsewhere in the world?

Greg Bearman: Well, there are economic interests. And I think--let's take the security interest first.

Peter Robinson: Okay.

Greg Bearman: Both sides of the aisle agree on this. John Kerry speaks forcefully about the potential of failed states and the security imperative. George Tenet, former CIA director, acknowledges it. Colin Powell said this is the greatest weapon of mass destruction on earth. In 2002 the White House national security strategy, that document made the revolutionary assertion that for the first time weak states pose a greater threat to our national security than strong states in the wake of the collapse of Afghanistan and terrorism.

Peter Robinson: Right, chaos tends to breed the conditions for terrorism, is the argument, right?

Greg Bearman: Exactly. Africa is, has been a staging ground for terrorism. It's been a site of recruitment. We saw the embassy bombings in '98, Osama bin Laden found succor in Sudan. If you ask what today is making states weak, in Africa it's a combination of things, but perhaps primarily it's AIDS, which is just cutting a swath through the adult population.

Peter Robinson: Next, just what is the scope of the global AIDS problem.

Title: sHIVer

Peter Robinson: I'll quote you again, you are a very good place to start. "Over the last 20 years, 25 million people around the globe have died of AIDS. More than 40 million people are currently affected. Reasonable estimates predict that by the end of this decade there will be 100 million or more HIV infections, and 25 million AIDS orphans," close quote. Does that sound reasonable to you?

Carol Adelman: Yes.

Peter Robinson: It does? All right, now help me to understand the distinction between HIV and AIDS. In the early days it used to be that one led pretty directly to the other, right? So if you got HIV, that was in effect a sentence of AIDS. And ultimately a sentence of death, right? But now that's not the case in this country, or in rich countries, because of the anti-retroviral--explain this, help me out now, AIDS can be treated now?

Carol Adelman: Absolutely, with anti-retroviral drugs developed by our pharmaceutical industry.

Greg Bearman: Which are now available for less than $1 per day if we procure generics.

Carol Adelman: I have a big disagreement with that.

Peter Robinson: Okay, we'll come to that in a moment. But when you say by decade's end there will be 100 million or more HIV infections, that does not necessarily read, there will be 100 million or more condemned to death?

Greg Bearman: That's right.

Peter Robinson: If things worked out, if by some policy or miracle all those 100 million people could receive adequate treatment that 100 million figure is 100 million who need medicine but who could go on to lead quite full and extensive lives, is that right? Do I understand that correctly?

Greg Bearman: Potentially, but there is a huge gap, almost really a chasm, between what we're planning on doing and getting to your sort of ideal scenario. WHO, speaking for the entire global community, including the U.S., their plan is to get 3 million people around the world on treatment by 2005. Now you talk about the potentiality of 100 million infections, and the leading technical agency in the world with its greatest ambition, which would be a difficult goal to meet, to get 3 million people in treatment, there's a huge gap there.

Peter Robinson: Let me put, Carol, let me ask you to comment on this first. What I'd like to do is put up in brief summary form what President Bush has proposed, and then you may both hammer away at it and let us know where it's strong but also where it's weak. George W. Bush last year's State of the Union address, I quote: "Tonight I propose the emergency plan for AIDS relief, a work of mercy--that's the argument that you accept--a work of mercy beyond all current international efforts to help the people of Africa. I ask Congress to commit $15 billion over the next five years including nearly $10 billion in new money in order to turn the tide against AIDS." Three points--I'm quoting now from the White House fact sheet--but principal points in his program. One, to prevent 7 million new infections. Two, to treat 2 million HIV infected people, all this in sub-Saharan Africa. And three, to care for 10 million HIV infected individuals and AIDS orphans. What do you make of that?

Carol Adelman: It's a phenomenal plan. And what he decided to do, which is very important, is to carve out those countries where we have the highest prevalence of AIDS, to not try to just do it everywhere, carve out those countries, and the ones that he has chosen have something like 50 percent of the AIDS prevalence throughout the world, and do it right, and actually be able to make a difference in those countries.

Peter Robinson: You give the Bush plan unqualified support?

Carol Adelman: Oh, yeah.

Peter Robinson: You do?

Peter Robinson: Oh, yeah.

Peter Robinson: Okay. Greg?

Greg Bearman: I, well, I agree with absolutely everything Carol said up until that last point. What we have in place now is a 5-year emergency plan. The goals that you outlined are good, a huge historical step up in terms of priority, in terms of funding. But not nearly enough. What we lack, and what we've always lacked, is a real long-term viable strategy, and that would entail working in greater concert with our international partners. It would entail a much greater degree of resources up front. Much greater concentration on capacity building in these countries so they can deal with this problem in a sustainable fashion.

Peter Robinson: Onto an issue that's been debated for years now: patented drugs versus generic and copycat drugs.

Title: An Ounce of Cure?

Peter Robinson: Point two of the president's plan, to treat 2 million HIV infected people. With what kinds of drugs and from whom will they be purchased?

Carol Adelman: Well, our government has taken probably one of the most responsible positions on the HIV-AIDS drugs. They have said, we will procure any drugs, whether they are copy drugs made by Indian companies that steal our patents, or patented company drugs, as long as they can be shown to be safe. Now the WHO has set up...

Peter Robinson: Shown by whom?

Carol Adelman: Shown by...

Peter Robinson: FDA, our own...

Carol Adelman: Now they're saying FDA. Because what happened was, the WHO set up a prequalification system that has not been rigorously testing the drugs. And consequently over the last month the WHO has had to take off five of the key drugs that they have recommended as not fit for treating HIV-AIDS, which proves the wisdom of the administration in doing what they did. They're saying, we will fast track...

Peter Robinson: We will buy the cheapest product that does the job that is medically sound?

Carol Adelman: Yes. Exactly.

Greg Bearman: They've been saying that. But this is a relatively new development where the U.S. has now said, okay, we'll entertain generics for FDA approval if they meet those regulatory process approvals, we'll procure them. But it took them three years to make that statement. They could have done it immediately. And I think that that does reflect a strong bias towards the U.S. pharmaceutical companies. Those drugs are three or four times more expensive.

Carol Adelman: They've always said they would, they would buy the cheapest drugs as long as they were safe. And the Indian drug companies don't have to have their drugs approved or tested for export, and that's a scary thing.

Greg Bearman: Well, they said it, but they haven't done it.

Carol Adelman: Well, they're doing it now. And this is the first time the money, the Congress didn't even give them the money until February. So this is the first time they've had to procure drugs, with the system in place.

Greg Bearman: Three years too late in my view.

Carol Adelman: They didn't have the money, so I don't know how that can be three years too late.

Peter Robinson: Well, but you're happy? It doesn't cause either one of you a little fillip of concern that the government of the United States is now committed the resources of American taxpayers to buying products produced by patent violators? Neither of you is worried about that?

Greg Bearman: So you think that if in the United States 25 percent of our adult population was infected with a lethal disease, and we weren't getting access to the life-extending drug treatment that was widely available in another part of the world, that we would not think seriously about violating patents to save our life? I mean this is an incomparable human emergency. Societies are getting absolutely decimated. I understand the reason, there are two sides to the discussion. But this is an emergency...

Peter Robinson: The matter is so pressing you just have to move ahead.

Greg Bearman: Absolutely.

Carol Adelman: It's not an issue. The companies have already reduced their prices to almost the same price as the copied Indian drugs. The companies have long said...

Peter Robinson: The American or at least...

Carol Adelman: Yes, the American companies. Those prices are already down to the virtually the same levels. In some cases average prices are even lower.

Peter Robinson: Because of production efficiencies or because they've just been forced by the marketplace...

Carol Adelman: No, because they've said this is an international pandemic, we want to help. And the companies have said, we will allow our patents to be broken for these diseases. The danger comes though when the WHO in doing what it's doing now with their intellectual property commission is trying to extend this to all of the other drugs that our companies produce, and that will bring about a loss of jobs and a lowering of the economy in this country.

Peter Robinson: Enough of George W. Bush. I now wave my wand, and you're president. In fact, we make you dictator.

Greg Bearman: Okay.

Peter Robinson: For the purposes of this program. What would you do? How would you change his program? What is your program?

Greg Bearman: I would take a step back, and instead of, instead of a five-year emergency plan with good, laudable, but relatively arbitrary goals and a unilateral approach, I would say, blank canvas, let's devise a long-term strategy for truly curbing if not ending this pandemic.

Peter Robinson: Who's the "let's"? Through what body?

Greg Bearman: The U.S. is the global leader. We are doing a great job comparatively measured against other wealthy nations. We're spending about twice as much as the rest of the world combined on this issue. And that positions us to be the global leader, to convene international partners, international institutions, other countries, foundations, to actually devise a shared strategy. This is a shared threat. It's a shared problem. The U.S. can't solve it alone. We shouldn't have to. Let's devise this strategy, make the resources available, have shared goals, shared approach, shared budget.

Peter Robinson: Now, how do we get the African leadership to face up to their responsibilities in the AIDS crisis?

Title: Nowwhere in Africa

Peter Robinson: Robert Goldberg, writing in National Review, Robert Goldberg of the Manhattan Institute, Uganda, uses Uganda as his--"Uganda as a success story, reduced its HIV rates from the highest of any African nation--14 percent in 1993--to the lowest, 5 percent, in 2001. But Uganda's gains are the result of actions taken by its president, and religious leaders, to promote abstinence and sexual fidelity among the young and to ensure that its public health activities were free of corruption," close quote. It's not a question of having the United States or the Europeans pour money into the problem. It's a question of having leaders in infected countries take responsibility for the problems themselves.

Greg Bearman: I think it's absolutely true. Leadership and resources, that's the recipe, that's what's been there in places like Uganda where this has worked. You have to look first to the countries that are most acutely affected, and their leadership there. But because now incidence rates have reached such a level, it's imperative that the international community does offer resources, does offer assistance.

Peter Robinson: You were born in this country, but your country comes from South Africa, so you're very familiar with the situation there. President Mbeki--am I pronouncing that roughly correctly?

Greg Bearman: Mbeki.

Peter Robinson: All right. Now there was a period of years when he more or less refused to acknowledge that AIDS was a growing problem?

Greg Bearman: A great tragedy.

Peter Robinson: And what should we have done to him? The properly duly elected leader of the nation? In other words, if there is a lack of leadership in an African country, what are we supposed to do?

Greg Bearman: Well, I think diplomacy is a very important tool or weapon in our arsenal on this. And Al Gore and others did try to engage Mbeki on this. But we could have done much more. If we had the carrot of resources available, such that we could empower leaders to engage it, to address it, that will help move them. It has helped move leaders.

Peter Robinson: I see. You buy all this?

Carol Adelman: One thing we have to realize, those of us who have been in foreign aid for many years, and following these issues, and kicking around...

Peter Robinson: You did this long stint at the Agency for International Development.

Carol Adelman: Yes, ten years in the Agency for International Development, was a presidential appointee in charge of our aid in Asia and the Middle East.

Peter Robinson: And you have written, quote, I'm quoting you now, Carol, "There has been no demonstrated relationship between foreign aid money and lower AIDS infection and mortality rates, despite billions of dollars spent on AIDS programs by donor agencies."

Carol Adelman: And that's a sad commentary. Because it gets to...

Peter Robinson: Because spending the money doesn't do any good, or because we've spent it in a profligate, unregulated, unexamined way?

Carol Adelman: The latter, we have not spent it well. And there is something I want to say about the infrastructure point that Greg is talking about, and that is, in 1977 there was a big international health conference in [Oma Ata]. And that conference called for the world to put billions of dollars into health care infrastructure. Since 1977 $100 billion has been put into primary health infrastructure, the same infrastructure that you're now saying we don't have. So I was disappointed with your report that you were sort of blaming the America, or blaming the hand that's feeding people and not looking at where did that money go? And how can you possibly suggest that we just go ahead and put more money in until we know why that money didn't go anywhere? And there is nothing to say--where is it written that African governments should only be putting three percent of their GDP into health? If South Africa goes out and puts $7 billion in to submarines, I mean what threat are they experiencing that they couldn't put that $7 billion into HIV-AIDS? So this question of leadership and other governments stepping up to the plate, this is where I think your report, and your perspective, needs to get a lot broader.

Greg Bearman: Money has been spent, but it's something that I think a lot of people don't understand. There is a huge gap--when you look at Western economies, we spend you know, some of the advanced Western economies spend on the order of $3-4,000 per person per year on national health. In sub-Saharan Africa that can sometimes be, as Carol well knows I think, $5-10 per person. Ethiopia spends $1 per person per year. These countries are grossly inequipped to deal with a crisis of this magnitude, and at the same time they have tuberculosis, malaria, other problems. We know that with providing them with basic infrastructure, physical equipment, human capacity to deal with this, this is not an insoluble crisis.

Carol Adelman: The reason that things aren't working in Africa is that the governments have tremendous corruption. They don't pay their doctors, so the doctors go to the public health clinics in the morning, don't do anything, set up office in the afternoon and charge people. They siphon off drugs, they sell them on the market, and these are, we all know this. And so these governments have to get their act together, and be held accountable.

Peter Robinson: Let's go back to the proposition with which we began, that the center of the crisis will soon shift to Eurasia.

Title: Death on the Orient Express

Peter Robinson: Nick Eberstadt in Foreign Affairs again: "Moscow, New Delhi, and Beijing, could take steps to mitigate the coming disaster, but so far they have not." Russia, India and China--these are countries with fewer resources per person than the United States but far more resources than sub-Saharan Africa. Are your arguments that we have a moral obligation and so forth the same in the case of Russia, India and China the same as they are in sub-Saharan Africa? Is it up to us to stop the Eurasian pandemic?

Greg Bearman: I think it's a mischaracterization, Peter, to say that I think it's up to us. I profile in the book the neglect among African leaders, and I say that explicitly they have primary responsibility. But I think that because of the disparity in resources, because of the magnitude of the crisis, we need to sort of stop finger pointing and saying whose to blame and say, how are we going to solve this?

Peter Robinson: Sub-Saharan Africa is really a special case.

Greg Bearman: It is a special case because of the poverty.

Peter Robinson: The total impoverishment.

Greg Bearman: We have to look first to leadership amongst Russia, India and China's national leadership. It has been abysmal. You see this same vicious cycle of abdication you saw in sub-Saharan Africa. We now see it in Eurasia. I think there is a lot we can do here, diplomatically, to try to help these leaders engage on this.

Peter Robinson: But it's just a different starting point. It's just very hard to resist the feeling that these countries really ought to handle it themselves, they're great big countries with growing economies, right? Isn't that right?

Carol Adelman: We clearly can share technology, we can link our scientists with them. Because treating AIDS is complex. We can do that, and we can be helping them in that regard, technical assistance. But to be thinking that we should bankroll this, for countries that do have the funds to do it...

Peter Robinson: Now let me ask you, if it so clearly in their self-interest to address the problem, and I am completely persuaded by your arguments that it is, if Russia, China and India are going to suffer huge numbers of infections, purely from a point of view of economic self-interest, you don't want that eating away at your economy, why the denial? Why are these countries so backward in addressing an obvious problem that is going on?

Carol Adelman: Well, I think in the case of China, it's clearly this is, for them, it's a Communist government. They don't want to have their system criticized, and they've been very careful in covering up things. Just as they do with a lot of other health problems.

Peter Robinson: I see, so they cover them up from the outside world, but they address them...

Carol Adelman: No, they haven't been doing that either. Look at SARS, how long they let that simmer. And it just shows, the importance of having democracy and freedom and open press is so critical to all of these countries.

Greg Bearman: It is. I'm actually most hopeful in China because of the SARS experience and how they got crushed on tourism and the economy. China does seem to be opening up a little bit more. It's still early, they're still ambivalent. But in India and Russia, it's the sort of complex of reasons, and it's the same thing it's been in the past. It's that this still evokes notions of sexuality or behavior that people are uncomfortable dealing with. Another thing is the fundamental latency of this disease, and you alluded to it. It's the idea that even as people are getting infected, there is a lag time until which they become sick or die. So for leaders who are inclined to turn away, it's another insidious dynamic.

Peter Robinson: Last topic, predictions.

Title: Getting Better All the Time?

Peter Robinson: Last two questions. One, sub-Saharan Africa, in some meaningful way, five years from now, after the Bush program has really kicked in and run its course, will things be tangibly better in sub-Saharan Africa, Greg?

Greg Bearman: Things will be better than they would have been if we hadn't done anything. But things may--some things may actually be worse than at the sort because of the progression of this disease. We are not thinking long term enough. Our effort is not comprehensive enough. There is much more that we can do, and millions, tens of millions of lives hang in the balance.

Peter Robinson: Carol.

Carol Adelman: Jury is out. I think we are putting about all we can put into this, and this question of trying to put more into the health infrastructure, we have an entire additional foreign aid budget that is doing separate health infrastructure. So there is money going into health infrastructure from the World Bank and AID and other donor agencies.

Peter Robinson: But your fundamental stance is one of greater skepticism because we're pouring it into corrupt countries.

Carol Adelman: Right.

Peter Robinson: Where the government, there is that much corruption, is that right?

Carol Adelman: It will work if these leaders are held accountable, and that will be our most important message to them.

Peter Robinson: And now Eurasia, let me quote Nick Eberstadt one last time: "China, India and Russia together could experience more HIV infections than AIDS deaths over the coming quarter century than the entire planet has thus far." So he's saying that there could well be in the neighborhood of 25 million deaths from AIDS in Eurasia. Will that take place, or will indeed New Delhi, Beijing and Moscow wake up? Will we wake them up? What do you think? What's the prospect?

Greg Bearman: At our current trajectory the prognosis is frightful, and it's highly--you know, it's highly possible. As you said forecasting is very difficult, so one can't do it with precision. But, but it's highly possible that these places...

Peter Robinson: You are not encouraged?

Greg Bearman: It's bleak. But I think there is so much that we can do to preempt whatever stats forecast.

Peter Robinson: Carol?

Carol Adelman: Yeah, I think it will not be as bleak in India and Russia, just because these societies now are more open societies, and the press will call these governments on it just like South Africa. The press, and the fact that they allowed NGOs in that country...

Peter Robinson: Nongovernmental organizations.

Carol Adelman: Yeah, nongovernmental organizations, to speak up freely, the only reason South Africa started treating is that they were sued by an NGO to treat. And so China being more communist and insular is probably not going to do as well as India and Russia.

Peter Robinson: You're saying that Russia and India have their own Greg Bearmans who are, who either are or soon will be screaming and saying, this must be dealt with.

Carol Adelman: Or maybe even better Greg will go over there and do it.

Peter Robinson: Carol Adelman, Greg Bearman, thank you very much.

Greg Bearman: Thank you.

Peter Robinson: I'm Peter Robinson for Uncommon Knowledge. Thank you for joining us.